Does Medicare Cover Pneumonia Shots?
Key Takeaways
- If you have either a Medicare Part B or a Medicare Advantage plan, Medicare will fully cover your pneumococcal vaccine(s).
- Keep in mind, Medicare will cover 100% of the cost as long as you visit a Medicare-approved healthcare provider that accepts assignment.
- Two different pneumonia shots are available. The Pneumococcal conjugate vaccine (PCV13) and the Pneumococcal polysaccharide vaccine (PPSV23).
Pneumococcal pneumonia is a bacterial infection of the lungs which causes around 400,000 hospitalizations every year in the United States. Older adults are at higher risk of serious illness from pneumococcal infections like pneumonia, meningitis, and bacteremia (infection of the bloodstream).[i]
Fortunately, there are two different vaccines available that can provide protection from serious pneumococcal infections. And, if you have Original Medicare (Part A and Part B), both shots are covered under your Part B coverage.
The vaccines are also covered by all Medicare Part C (Medicare Advantage) plans.
Pneumococcal vaccines are also commonly called pneumonia vaccines.
If you have either a Medicare Part B or a Medicare Advantage plan, Medicare will fully cover your pneumococcal vaccine(s).
This article will discuss the two different pneumococcal vaccines, what they cost, and who should get them.
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How Much Does Medicare Pay for Pneumonia Vaccine?
The good news is Medicare pays for the entire cost of pneumococcal preventive vaccines. Whether you have a Medicare Part B plan or a Medicare Advantage plan, both cover the full cost of the vaccines.
Keep in mind, Medicare will cover 100% of the cost as long as you visit a Medicare-approved healthcare provider that accepts assignment. This means the provider agrees to accept Medicare-approved reimbursement rates for the vaccines.
If you have a Medicare Advantage plan you may need to visit an in-network provider to get 100% of the cost covered.
Plan ahead before visiting a provider to make sure they accept assignment. You can call your provider (pharmacy, clinic, or doctor) directly, or check with your individual plan to find a covered provider near you.
Will Medicare Pay for Both Pneumonia Shots?
Yes, Medicare pays for the two types of pneumococcal vaccines approved for use in the United States.
The vaccines offer protection from severe pneumococcal infections caused by common strains of the bacteria Streptococcus pneumoniae.[i] But you should know pneumonia may be caused by bacteria, viruses, or fungi.
Pneumococcal vaccines don’t protect against every strain of bacteria that cause pneumococcal infections. There are over 90 types of pneumococcal strains.
- The Pneumococcal conjugate vaccine (PCV13) (Prevnar 13®) protects you from 13 different types of pneumococcal bacteria. It is an injection given into a muscle by a healthcare professional.
- The Pneumococcal polysaccharide vaccine (PPSV23) (Pneumovax 23®) offers protection against 23 different varieties of pneumococcal bacteria. The 11 extra strains covered by PPSV23 vaccine are responsible for around 32% to 37% of invasive pneumococcal disease (bacteremia, meningitis) in older adults. It is an injection given either under the skin or into a muscle by a healthcare professional.
Both vaccines may cause some mild side effects like pain, redness and swelling of the injection area, fever, and tiredness. These generally go away after a few days. In rare cases, a serious reaction is possible.[i] If you feel you’re experiencing more serious reactions after a pneumococcal vaccine, contact your doctor right away.
Let your healthcare provider know if you’re allergic to any part of the pneumococcal vaccines or ever had an allergic reaction to a vaccine.
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What Pneumonia Vaccine is Recommended for Seniors?
The current guidance by CDC recommends adults 65 years and older get the PPSV23 vaccine to protect against pneumococcal pneumonia and other types of severe pneumococcal disease.
You may need both the PPSV23 and the PCV13 shots if you’re at higher risk (example: living in a nursing home or long-term care facility). You and your doctor will decide if you need the additional pneumococcal vaccine (PCV13).
Symptoms of pneumonia include cough, chills, fever, trouble breathing and chest pain. In serious cases, pneumonia can be life-threatening and require hospitalization.
Pneumonia infections may be caused by multiple organisms (bacteria, viruses, fungi).[i] You are at increased risk of developing pneumonia after a respiratory viral illness like influenza (flu) or other respiratory infections. So it’s a good idea to get the flu shot each year.
Individuals 65 years and older, children younger than two years, people who smoke, and those with other health conditions like asthma, diabetes, chronic obstructive pulmonary disease (COPD, liver, heart, or kidney disease, and immunocompromised people are at greater risk for serious pneumococcal infection.
Does Medicare Cover Pneumonia Shots for Seniors?
Yes, Medicare Part B and Medicare Advantage plans both cover the pneumococcal vaccines for those 65 years and older. Whether you need just one shot or both, Medicare fully covers the shots.
If you’re eligible for Medicare, you automatically qualify for the PPSV23.
Also, Medicare will cover the PCV13 vaccine as long as they are given at least one year apart.
Am I Eligible for a Free Pneumonia Vaccine?
Yes, if you meet Medicare eligibility requirements, you qualify for the pneumococcal vaccine.
Medicare Part B covers specific preventive vaccines like pneumonia, hepatitis B and influenza (flu). Part B also covers rabies and tetanus shots after exposure.
Part B requires a copayment and 20% coinsurance for most services, but your pneumococcal vaccine is free of charge.
Medicare Advantage plans are Medicare-approved private insurance plans required to cover the same preventive vaccines as Part B plans. Medicare Advantage plans may also offer extra benefits like dental, and vision coverage and more. You may need to visit a network provider to be eligible for free vaccine coverage.
Find the Medicare Advantage plan that meets your needs.
Find Plans Today Should Seniors Get Pneumonia Vaccine?
Getting your pneumonia vaccine is important. According to the CDC, pneumonia causes more than 43,000 deaths each year in the US.[i] Your immune system weakens with age and this can make you more vulnerable to infections like pneumonia.
Pneumococcal pneumonia is highly contagious and easily spread through air droplets from coughing, sneezing, or contact with surfaces with the bacteria. The PPSV23 vaccine is around 60% to 80% effective against severe pneumococcal disease in older adults. Even if you’ve had pneumonia in the past, you should still get vaccinated because there are many pneumococcal strains.
This is why CDC recommends everyone 65 years and older get vaccinated with the PPSV23 shot to prevent serious infection and complications.
Talk with your doctor to learn more about the benefits and risks of pneumococcal vaccines.
Sources
- Pneumococcal Vaccines (PCV13 and PPSV23). immunize.org
- Pneumococcal Disease. cdc.gov
- Pneumococcal Vaccine Timing for Adults. cdc.gov.
- Pneumococcal Vaccination: What Everyone Should Know. cdc.gov.
- Pneumococcal Pneumonia and Invasive Pneumococcal Disease in Those 65 and Older: Rates of Detection, Risk Factors, Vaccine Effectiveness, Hospitalisation and Mortality. ncbi.nlm.nih.gov.
- Pneumonia. cdc.gov.
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